Good morning Hank, it's Tuesday.

So five years ago, when I was 40, I feel like I was a fairly well-informed person back then, but I did not know that the world's deadliest infectious disease was tuberculosis. In fact on some level, the reason I'm so obsessed with tuberculosis, like to the extent that I'm on vacation and yet still reading a book about Sir Arthur Conan Doyle and his contributions to tuberculosis research, is because I didn't know that tuberculosis was the world's deadliest infectious disease. Like, what was so wrong with my ingestion of information that I believed that tuberculosis was, like, a 19th century problem. 

And I've seen this a lot at parties and in conversations with friends and every other time that I'm in a social situation and I bring up tuberculosis, which is every time I'm in a social situation. People will be like, "Really? I kinda thought that was a problem of the past." Anyway, I was talking to a public health official recently, like a fancy person in the world of global health, and they said that the problem tuberculosis has is that it doesn't have a constituency. Like, illnesses that have what he called a "global constituency" tend to get much more attention and the problems we pay attention to tend to be the problems that we solve. Like, look at the other three great infectious diseases of the 21st century. So far. The 21st century so far. Let's not jinx ourselves. 

We've got Covid-19, which had a global constituency from day one. Powerful people and powerful countries recognize that their lives and communities were going to be upended by Covid, and so there was an immediate immediate expenditure of resources to be like, "We-we got to figure this out."

Then you've got HIV, which primarily affected marginalized people which made it harder to build that global coalition. Right, like in the 1980s, organizations like ACT UP emerged and through direct action and tons and tons of activism were eventually able to get the attention of governments. But like, I think that it was four or five years after HIV first emerged in the United States that Ronald Reagan, the president into the United States, first mentioned it. And then even after all the work to discover and disseminate new effective treatments, those treatments weren't available to people in impoverished communities. HIV activists in the United States and Europe and also in the Global South came together and worked together to build that constituency. As a result, HIV deaths over the last 20 years have dropped by more than 50%.

And then lastly, you have malaria. Now, organizations worked incredibly hard to get malaria into the center of health conversations, especially in the early 2000s which is when the malaria death rate finally started to drop.

Anyway what we're really talking about when we talk about a "disease having a constituency" is a disease having a constituency that includes people from rich and powerful communities, people who have access to the megaphones of the social internet, and so on, right. Because like tuberculosis has a constituency. Over 10 million and people get sick every year. There are so many activists working so incredibly hard to bring attention to this crisis, and yet, I still didn't know anything about it because I wasn't listening to those voices. I really didn't even know how to listen to them.

So five years ago, when, for instance the young women who would eventually sue the Indian government to make sure generic bedaquiline could be available for production, were engaging in activism, I didn't know about that activism. And so, I would argue that actually what TB needed was for people in the rich world to pay attention. And I feel like that is beginning to happen, not primarily because of me, although I will not shut up about this. Believe me. But because people are beginning to understand that the world's deadliest infectious disease in 2023 is curable. And the cure isn't just medicine, it's also being able to find cases and diagnose them quickly and effectively so we know not just whether they have TB, but whether the TB they have is resistant to certain antibiotics. And it's about preventing TB illness once we've identified those cases by giving their close contacts, people who live inside their household, one month of preventative treatment so that they don't get sick with TB. And it's about making sure that every person who lives with tuberculosis can access curative treatment.

And so I think there's a lot of reasons why people like me weren't paying attention to tuberculosis. It kills slowly instead of dramatically, it is a much bigger problem in low and middle-income countries than it is in rich ones, and most of all, it's a disease ultimately caused by crowded living conditions, by malnutrition, and by other symptoms of what is really the world's leading cause of death: Poverty. All of that has meant that for too long fighting tuberculosis has not had the global constituency that it needs, but I hope that's starting to change.

Like, when I was a teenager right at the beginning of the internet, there was this IRL viral meme: Andre the Giant has a posse. You'd see these stickers everywhere and everywhere I saw them they would bring me immense joy. I love the idea that Andre the Giant had a posse that, like, there was a group of people who were with Andre the Giant, that he would no longer be cast out and marginalized for his size because Andre the Giant has a posse now. And that's what I want for people living with tuberculosis and the activists fighting it is for tuberculosis fighters to have a posse. For the world, especially the rich world, to say, "You are no longer alone. We will stand with you and we will fight for you."

I genuinely think this community helped lead a big step in that direction last week and I am overwhelmed with gratitude, but it's step and we need to make more of them.

Hank, I'll see you on Friday.